06080213 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,�CONTRACkTORINFORMATION e,�,
e�tiiw_�rc,;
auILDING ADDRESS: AFFORDABLE WATER HEATERS PERMITNO.05120075
0041 PHAR LAP DR
OW NER'S NAME: PERMIT ISSUE DATE
JOWOON KIM 24707 SAN FERNAND RD 12/14/2005
NE: SANITARY NO. CONTROL NO.
(661) 259-7131
ARCHITECIENGINEER: Ct( BUILDING PERMIT INFO
L y ELECT PLUMB MECH
u0o
LICENSED CONTRACnder p DECLARATION
uC IWmby affirmiA 1amdhe licensed Bu undernd Incoras. Chapter ode.t9(commencing Job Description
ZsW wiNSec.,..d10)af Divixionlof the BusinmaneProfessiuu Cotle.aMmyliccna is g
infeBmreaanderca 6 WATER HEATER Ay, �t�1 ''as, e
j
Zs u,
Licrnsc Clazs��Lic.N
nFq Date/ /s/ A RC H M��gnachm _ATON F-0 13
D.0 IundersunJ my plans shall Wused as public retards �� �uO
Jy
g G Licensed professional
OWNER-BUILDER DECLARATION
iZ 1 Wmhy,affirm Net I am exempt from the CanuacsaYs License Law for the
i
00 following mission.(Section 7031.5,Business and Professions Cade:Any city or county flt�
K m which require improve,
a permit so construct,alter. demm olish, repair any structure $400
°iin prior it)its issuance,also require the applicant for such permit to file a signed statement
R< Nm he is licensed nor unttoNcpmvisiomnftheContractor'sLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuation
est (commencing with Section 7000)of Division 3 of the Busies and Professions Coec)or
i Net he It exempt therefrom and and the hul for ft alleged exemption.Any violation of
Seefian 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mole than fsro hundred doll.(5500). P Occupancy Type
Lu owneof Ne propeny,or myemntendedwiNwage ulMirrole 0,14,8 udon,
will do 0,work.ands: he Cominot intended do Tortola(Sec.70,14,Business
and property who
Code:The Contractor's License law hoe not apply lf in owner of Required Inspections
propertywho buildsorimpmtsuchicon,and who docssuchwork h roffe edthrough his
own employee,provided catsuch improsoldwit crone year fc mpletired for ole If.
however.the building or improvement is sold within are year of campkuo Ne owe of
owner-
Wilder will have the buretn of proving NW at did last Mid o improve for forr ne purpof
sale.).
D 1,as owner of the property,am exclusively contracting wish licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li.
come law does not apply to an owner of property who Wilds or improve cemon,and
who contracts for such projects with acontrutor(s)licensed pursuant o use Contractors
License Law.
D 1 am exempt under Sec. B&P C for this won
Owner Dam
IC31] WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decluations:
1 have and will maintain aCeri ficae of Consent to self-insure for Workers Compton.
"(W" csfubc
on,u provided for by Section 37W of the Ia h r Code,for tW performance of the
rk for which this permit is issued.
1 have and will maintain Wakefs Compensation lazu ar ce,az required by Section
labor Cade.for ee perfmor onceofNe work forwhwh Nr'permit l issued.
Workefs pcnuuon lnsurana eartier and Policy number are:rtier. n4e—r4wD Pull,No.:J6�5335 Z60�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbl scmiorl ocod nottic completed if the permit is foonc hundred dollars($100)
or less.)
I certify Nat in thc performance of the work for which this Permit is issued.1041 not
employ any person in any manner sn as to become subject to the Workers'Compenuuon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Inter Coec,you mut
.,0 faMwiN comply with such provisions or this Permit shall W deemed evoked.
Z'y CONSTRUCTION LENDING AGENCY
[r Ihereby air-that Vert is a construction lending agency for the performanx of
D: the work for which this permit is issued(Sec.3097,Ci,C.)
W�Q Lender's Name
z Lenders Addrus
U O 1 certify that 1 haus red this application and sum don the a Wve information is
Is, F corrett 1 agree to comply wit all city and county ordinsrrccs and stale laws relating to
U building construction.and hereby authorise epre,madws of this city to enter upon the
,leve-menudg a pmpc, for inspection pmpawhich ms.
F y (we)agree to save,indemnify and keep harmless the City of Cupertino against
V) incoiuepuence of the
.,.a which may in any way acrotic against and City
UZ inconsequence of Nc grnming of this permit.
APPLICANU UNPERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO{)RQ,' ATIONS. /� `
S gnnum of Apple Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Dae Type of Roof
Will the applicant or future Wilding occupant a oro or handle huandous material
u ecfinoe by tW Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
CWe,Section8512(ap
❑tact I +rr- All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mere Wilding occupant use equipment ordc.icaa which If a roof is installed without first obtaining an inspection,I agree to remove
tit hanNous air conuminams az defirsed by the Bay Area Air Quality Management all new materials for inspection.
nrlcR
Dyes Nu
I have read the W>ardnusmamilals requirements under Chaper6.95 of Ne Califor.
nia Health&suetycode,Sec255(15.8533 and 25534.1 understand that if the Wilding
doesnotcurmntyha ate 4Natitismymspmnibilitymnatily Neoceupantoroe
requircmc whit uta npriorWiss ecofaCcniB<anofOccu ars Signature of Applicant Date
L 7
Owneroraumori=dagem Dam All roof coverings to be Class "B"or better
12/06/2005 08: 46 66122599556 AFFORDABLE WATER HET PAGE 02/02
CITY OF CUPERTINO
WATER HEATER �y�aoa7S
OF
CUPERTINO PERMIT APPLICATION FORM
AFN# Date:3a� l Fl Da 7
Building Address:
100qt V1. r o.P Pr.
Owner's Name: Phone#
Ito -Ooor, irr �IdEC'c)5� " �7
Contractor: Phone: (o@ i License#:
db e lJaTe eaters 051 .113 1 C„ 11 oBu cess License#:
Contact: Phone: r vj Pew
co'lT � ��1e(�eid oSav a�tySo
Building Permit Info:
Bldg ❑ Elect ❑ Plumb f� Mech ❑
Job Description:
RePIAe.e b� atlov� WgTeT N2a7er ($Q me IoCarian
Residential Commercial ❑
Cost of Project: q o0
Strapped ❑ On Platform El Bonded
New Location ❑ Replacement
Qty. if
Applicable Pee ID Fee Descri tion Fee Group
BPWIIEA'TER Water Heater/Vent BUILDING
PPEgNffnpEE Plumbing Permit Issuance PLUMBING
BENERGY ERgly BUILDING
BUSLIC Business License BUILDING